Every finding on record at Ultra Care Hospice, Inc

Upon patient record review, 2 of 14 (Patient #1, #9) did not contain evidence that a review was completed of all prescription and non-prescription medications, including herbal remedies that could affect drug therapy. This review includes, but is not limited to: • Effectiveness of drug therapy • Drug side effects • Actual or potential drug interactions • Duplicate drug therapy • Drug therapy currently associated with laboratory monitoring Patient #1: During home visit it was noted that patient was taking Magnesium Oxide 400mg, Vitamin B-12 1000mcg, Folic Acid 1mg, and Vitamin D2 1.25mg. These medications were not listed on the medication list. Patient #9: Latanoprost did not indicate which eye(s) to be applied to.

Upon patient record review, 2 of 14 (Patient #1, #9) did not contain evidence that the plan of care included all services necessary for the palliation and management of the terminal illness and related conditions, including medications and treatments: Patient #1: During home visit it was noted that patient was taking Magnesium Oxide 400mg, Vitamin B-12 1000mcg, Folic Acid 1mg and Vitamin D2 1.25mg. These medications were not listed on the POC. Patient #9: Latanoprost did not indicate which eye(s) to be applied to.

Upon patient record review, 1 of 14 (Patient #8) did not contain evidence that a revised plan of care included information from the patient's updated comprehensive assessment and must note the patient's progress towards outcome/goals from the plan of care: Patient #8: SOC 07/17/23; MSW conducted the comprehensive assessment on 07/19/23 and indicated need for monthly visits. However, IDG POC's dated 07/28/23 through 10/06/23 continued to include MSW assessment within 5 days of admission.

Upon observation, there was no evidence the hospice documented the cost savings achieved through the use of volunteers. Documentation must include the following: • The identification of each position that is occupied by a volunteer • The work time spent by volunteers occupying those positions • Estimates of the dollar costs that the hospice would have incurred if paid employees occupied the positions identified in paragraph (d)(1) of CFR 418.78 for the amount of time specified in paragraph (d)(2) of CFR 418.78

Upon observation, there was no evidence the annual report documents the use of volunteers providing day to day administrative and/or direct patient care services in an amount that, at a minimum, equals 5 percent of the total patient care hours of all paid hospice employees and contract personnel. No evidence that the agency utilized volunteers for at least 5% of the total patient care hours in 2024. The total usage of volunteers for 2024 was 0%.